SLR - June 2014 - Seiha Thorng
Reference: Machida J, Kameshita K, Okuzumi S, Nakamura N. “Flexibility of Idiopathic Congenital Clubfeet Treated By Posteromedial Release Without Talocalcaneal Joint Release.” Journal of Pediatric Orthopedics B. 2014 May; 23(3):254-9.
Scientific Literature Review
Reviewed By: Seiha Thorng, DPM
Residency Program: Saint Vincent Hospital/Worcester Medical Center
Podiatric Relevance: The surgical correction of congenital clubfeet is wrought with complications such as stiffness at the STJ, avascular necrosis of the talus, etc. At the end of the 20th century, there has been a significant shift towards the Ponseti method of serial casting and long term orthotics in the pediatric patient. The initial correction rate is high with this technique but relapses do occur in up to 40 percent of patients. In this population of failed conservative care, surgery is necessary to correct the deformity, but the majority of the complications seen with surgery may be avoided if the talocalcaneal joint (the STJ) is left undisturbed. This will preserve some of the natural flexibility of the feet necessary for normal function.
Methods: Sixty-five patients with idiopathic congenital clubfeet were treated within three months after birth by the same doctor with serial casting in a modified version of the Ponseti technique between the years 1991-1995. After 10 serial casts, x-rays were taken for re-evaluation. The calcaneus was observed in the frontal plane to determine whether it was rolling or not. On the lateral view and under maximum dorsiflexion, the tibial calcaneal angle was checked to see if it was less than 70 degrees. If the foot was corrected, the patients continue on to orthotics. If the foot were not, they went on to surgery.
The posteromedial release consisted of a medially based curved incision, Z lengthening of the Achilles, and Z lengthening of the posterior tibial tendon. Under tension, the posterior ankle joint, the CFL, and the PTFL were released to achieve full/normal dorsiflexion. From the medial side the TNJ, plantar fascia, and the abductor halluces was released. Thereafter, the foot was manipulated into corrected position and K-wires were used to temporarily transfix the CCJ, TNJ, and the ankle joint which were all removed after four weeks. The outcomes were rated according to systems described by McKay, ICFSG, and Laaveg-Ponseti. These patients were retrospectively followed until at least 15 years of age. Of the 65 patients, only 57 were available for follow up (88 percent ). Furthermore, the patients were divided into three groups. The cast treated group (CT), the late surgery group (LS – these people had surgery after walking and relapse of condition), and the early surgery group (ES – these people had severe cases).
Results: There were significant differences in the arc of motion of the hindfoot between the control and the three different groups between CT (22 feet), LS (332 feet), and ES (30 feet). The mean arc of motion of the hindfoot in group CT was 74 percent , in group LS was 64 percent , and in group ES was 53 percent. According to the McKay score, all the group in CT and LS and 92 percent of feet in group ES were rated as good or excellent. This is in contrast to the literature which has a 27 percent outcome of good to excellent. This can be explained by past surgeries involving the Cincinnati incision which involved a talo-calcaneal joint release in addition to the posteromedial release.
Conclusions: The authors of this study concluded that the talocalcaneal release is not necessary and may in fact be detrimental in the realm of pediatric congenital clubfoot surgery.